INVERSION OF THE UTERUS

tolbutamide 500 mg twice daily for many years, who was treated, on an outpatient basis, with 80 u of porcine calcitonin (Calcitare) administered subcutaneously daily for eight weeks for progressively increasing bone pain. She comp ained of drowsiness, headaches, shivering, cramps and nausea such that she required analgesics after each injection and after eight weeks refused to proceed further with the injections. During this eight-week period, her plasma glucose concentration rose to 25_6 mrnot/L and she exhibited persistent heavy qlvcosutia. Cessation of the calcitonin injections led to resolution of the above side effects, and her next recorded plasma glucose concentration was 11 _5 mmol/L and her urine was free of qlucose. Her diabetes has been well controlled since. From the foregoing, it would appear that diabetic patients receiving calcitonin therapy should be carefully observed to detect any deterioration in their control. D_ W_ THOMAS, D_ B_ FREWIN, P_ T_ JOLLEY_ Division of Clinical Chemistry, Institute of Medical and Veterinary Science, Adelaide, SA 5000_ The Department of Clinical Pharmacology, Royal Adelaide Hospital, SA 5000_


INVERSION OF THE UTERUS
SIR: Publication of the paper by Dr Gudgeon' prompts me to record the following case.
In 1937, as the only doctor in central Australia, I was called from Alice Springs to Hermannsburg Mission to a young Aboriginal woman whose native attendants thought that the afterbirth had not come away properlv. When I reached her, 36 hours had elapsed since the birth, and there was a completely inverted uterus protrudinq. It is likely that cord traction had been applied before the inversion occurred, and some traction had been applied to the protrusion. Subsequently, the raw endometrial surface had been treated in a traditional Aboriginal manner by a thick application of ashes, so that the surface was grey from overlying ash as well as from some ischaemia and was quite drv. I had no text or consultant for guidance to the orthodox treatment, although later I discovered that replacement after such a long interval was not recommended. So I scrubbed the surface of the inversion with warm water well lathered with Lifebuoy soap and, with gentle taxis, effected a reduction. Serous lochia commenced to flow at once. The puerperium was uneventful. 5 Grand View Grove, P_ J_ REILLY_ Dulwich, SA 5065_ t Gudgeon, C. W, MED J_ Ausr.. 1979, 2: 434 (October 20) PRESCRIPTION DRUG ADVERTISING SIR: The letter from the chairman of the National Medical Media Council (NMMC) (Journal, November 17) cannot pass without comment The "conclusion" and "discussion" sections of scientific papers are the correct and accepted places for authors to draw implications from their data. Data per se are value free and objective, but their interpretation and translation into policy decisions can, of course, never be so, except in obvious cases of logical necessity.
Ii is therefore no more or less "scientific" for Najman et alii' to conclude a case for government regulation than for the NMMC to hope for the continuation of self-requlation. Both positions These criteria may be only indirect indicators of the qualities deemed desirable by the Australian Health Ministers in 1974, but they are, pace Mr Ferris, as objective as we could make them.
Our article nowhere infers that the Voluntary Code for the Advertising of Therapeutic Goods has "foundered". Rather we show that, the comments of the Federal Minister for Health notwithstanding, this code has had little, if any, influence on Australian advertising practices. A similar finding appears to hold true in relation to the voluntary code for drug advertisements in Britain.
In response to our paper, the spokesmen for the pharmaceutical industry charge bias and raise doubts about the scientific validity of our conelusions. Mr Ferris in particular makes free with pejorative epithets ("deceptive", "fallacious", "biased" and the like), but offers only the sketchiest arguments in support. He may legitimate y object to our suggestions for change: the claim that we have disguised our opinions as "scientific truth" shows little respect for the intelligence of the readership. We make no apology for our "value judgment" that accuracy and relevant detail are necessary in advertising, and are intrigued by the implication that the National Medical Media Council has other values in this respect It is not clear whether Mr Ferris is reproaching us for falling into both the naturalistic fallacy and the "ought-from-is" fallacy, these being two very different thinqs. The naturalistic fallacy concerns the improper transfer of terms and concepts from one field of inquiry to another and is not obviously a problem in the paper in question. If one is to avoid ever inferring "ought" from "is", one would be precluded from advocating changes of any sort, no matter how unsatisfactory the current circumstances. This would be acceptable only to those who stood to profit from the situation.
As pointed out by Mr Ferris, we considered possible drug company behaviour in the face of attempts to monitor advertising practices. Mr Kelly's letter, with its barely-veiled threat to the survival of the Australian medical press, and THE MEDICAL JOURNAL OF AUSTRALIA in particular, shows how near the mark we were. Mr Kelly also manages to raise the bogey of the doctor's "freedom to prescribe": he does not DECEMBER 29, 1979 really explain how receiving accurate if perhaps less effusive advertising could affect this.
In the only factual criticism raised in either letter, Mr Kelly states that "all new drug advertising content is approved by the Federal Department of Health before a prescription drug is marketed". Inquiry of the Department reveals that, while this is largely true for classes of promotional literature not considered by us, in no case is approval needed for advertising in medical journals.
The Journal should receive appropriate credit for publishing a paper which, as Mr Ferris correctly points out, is implicitly critical of it It should, however, be noted that no journal is able to set its own "higher" advertising standards, Journals of the American Medical Association which attempted to do this in the United States were patronized far less by the pharmaceutical houses than were other medical journals until the American Medical Association accepted the standards which generally prevail eo.3 As noted above, Mr Kelly's letter suggests that the same would happen to THE MEDICAL JOURNAL OF AUSTRALIA if it tried to "go it alone" _ It was for these reasons that we suggested government legislation was needed to create uniformly high advertising standards.
The tone and content of the two letters emanating from the pharmaceutical industry provide additiona evidence that the industry will not voluntarily control the quality of its advertising copv. Mr Isouard' observes that: "Over the past three years, at Canterbury Hospital, we have been monitoring fetal-placental function by assaying maternal serum levels both of total oestriol and of HPL (human placentel lactoqen]. Both assays are now routinely performed for all the hospital's antenatal clinic patients in their last trimester of pregnancy" _Many other obstetric units, and many obstetricians in private practice, order these routine tests for all their patients.
Neither in Mr lsouards paper nor in any other publication has a double blind prospective study been reported evaluating the place of routine oestriol measurement in reducing penr.atal morbidity or mortality> Four prospective studies of the value of HPL have been made_ 2 -' Analysis of these papers indicates a considerable vanation of opinion. In the British study, Letchworth et alii observed that "the false positive rate is high and that roughly 60% of patients with low levels will have normal pregnancies"_ In the United States, Spellacy et alii found the measurement of HPL of value in the management of high risk pregnancies, but offered no comment on its value in all preqnancies. Ziatnik et alii, in the United States, found that routine H PL estimates "did not effectively predict those adverse perinatal outcome variables evaluated" _ Granat et alii, reporting from Israel, also failed to confirm the value of HPL as a screening test for all pregnant women.
At a time when expenditure on the health service must be curbed, obstetricians should not order tests which have not been adequately evaluated by approprialely conducted prospective double blind trials>